Pathomechanics of posterior ankle impingement syndrome in female ballet dancers

A dança é uma actividade de grande exigência atlética, que pode conduzir a um elevado número de lesões, particularmente na região do tornozelo, possivelmente devido à amplitude extrema do movimento articular de flexão plantar do mesmo, que os bailarinos, especialmente do sexo feminino possuem, para realizar a ponta e meia ponta tão características do ballet clássico (Kadel, 2006; Motta-Valencia, 2006; Russel, Kruse, Koutedakis, McEwan, Wyon, 2010). Estas posições de flexão plantar extrema produzem força excessiva na região posterior do tornozelo, o que muitas vezes pode resultar em conflito, dor e incapacidade, representando na maioria das vezes um desafio de diagnóstico. O síndrome do conflito posterior do tornozelo refere-se a um grupo de entidades patológicas que resultam da flexão plantar forçada do tornozelo, de forma repetitiva ou traumática, causando um conflito das estruturas ósseas e/ou de tecidos moles (Hamilton, Geppert, Thompson, 1996; Hamilton, 2008) . Os objectivos deste projecto são compreender os quais os factores de risco, mecânicos e funcionais que contribuem para a mecânica patológica da lesão descritos na literatura, e proceder a uma avaliação biomecânica do movimento de flexão plantar do tornozelo. Método. Realizar uma revisão sistemática de literatura dirigida á mecânica patológica do síndrome do conflito posterior do tornozelo em bailarinas e conduzir um estudo caso-controlo, cujo objectivo é avaliar, comparar e descrever o movimento da flexão plantar do tornozelo realizado ao efectuar os movimentos de ponta e meia-ponta, em bailarinas pré-profissionais com e sem lesão recorrente resultante do conflito posterior do tornozelo. Resultados. Não foram encontrados estudos relacionados especificamente com a mecânica patológica do tornozelo, no entanto vários estudos foram encontrados considerando as características clínicas e anatómicas assim como os procedimentos de tratamento, indicando que os principais factores de risco relacionados com a lesão se dividem em factores mecânicos e funcionais que quando combinados entre si e associados ao sobre-uso podem resultar no conflito posterior do tornozelo. Na avaliação do movimento foram observadas diferenças na actividade muscular entre os sujeitos com lesão e controlos, tendo sido possível a observação de um padrão na sequência de activação para um dos movimentos testados. Na oscilação postural e na rigidez do tornozelo foram também observadas diferenças entre os sujeitos bem como entre as posições realizadas. Conclusão. Concluiu-se que não sendo possível alterar a anatomia do bailarino, por vezes é possível intervir a nível funcional melhorando a capacidade técnica de forma obter um melhor desempenho e a actuar preventivamente em relação às lesões, uma vez que estas podem apresentar padrões cinéticos próprios, relacionados com a função muscular, a estabilidade postural e a rigidez articular.

Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement.

The purpose of this paper is to discuss the post-traumatic overload syndrome of the os trigonum as a possible cause of posterior ankle impingement and hindfoot pain. We have reviewed 19 athletes who were referred to our foot unit between 1995 and 2001 because of posterior ankle pain, and in whom a post-traumatic overload syndrome of os trigonum was diagnosed. All these patients were followed up over a period of 2 years. In 11 cases a chronic repetitive movements in forced plantar flexion was found. In the other eight cases the pain appeared to persist after a standard treatment of an ankle sprain in inversion plantar flexion. The diagnosis was based on clinical history, physical examination and X-rays that revealed a non-fused os trigonum. The confirmation of diagnosis was carried-out injecting local anaesthetic under fluoroscopic control. In all cases a corticosteroid injection as first line treatment was performed. In 6 cases a second injection was necessary to alleviate pain because incomplete recovery with the first injection. Three cases (16%) were recalcitrant to this treatment and in these three cases a surgical excision of the os trigonum was carried out. Our conclusion is that after some chronic athletic activity or an acute ankle sprain the os trigonum, if present, may undergo mechanical overload, remain undisrupted and become painful. Treatment by corticosteroid injection often resolves the problem.

Acute Posterior Ankle Pain in a Female Recreational Soccer Player

Os trigonum syndrome, a musculoskeletal disorder causing posterior ankle pain, occurs in approximately one in every 13 people. This condition can be challenging for the athletic trainer when evaluating an acute ankle injury. We present a unique case of an os trigonum successfully treated with conservative rehabilitation without a definitive diagnosis.

Posterior reversible encephalopathy syndrome after liver transplantation in children: A rare complication related to calcineurin inhibitor effects

PRES is a neuroclinical and radiological syndrome that results from treatment with calcineurin inhibitor immunosuppressives. Severe hypertension is commonly present, but some patients may be normotensive. We report herein two children who received liver transplants, as treatment for biliary atresia in the first case and for Alagille`s syndrome in the second one. In the early postoperative, both patients presented hypertension and seizures. In both cases, the image findings suggested the diagnosis of PRES. The CT scan showed alterations in the posterior area of the brain, and brain MRI demonstrated parietal and occipital areas of high signal intensity. Both children were treated by switching the immunosuppressive regimen and controlling arterial blood pressure. They displayed full recuperation without any neurologic sequelae. Probably, the pathophysiology of PRES results from sparse sympathetic innervation of the vertebrobasilar circulation, which is responsible for supplying blood to the posterior areas of the brain. In conclusion, all liver-transplanted children who present with neurological symptoms PRES should be considered in the differential diagnosis, although this is a rare complication. As treatment, we recommend rigorous control of arterial blood pressure and switching the immunosuppressive regimen.

A Posterior Interosseous Nerve Syndrome Associated With Spontaneous Rupture of the Extensor Pollicis Longus Tendon

Posterior interosseous nerve entrapment syndrome and spontaneous rupture of the extensor pollicis longus tendon are rare conditions. The authors describe the bizarre combination of a spontaneous rupture of the extensor pollicis longus tendon in a 82-year-old lady with a posterior interosseous nerve syndrome. As far as the authors know, this is the first description of such an association in the literature. Surgical exploration revealed compression of the posterior interosseous nerve at the proximal portion of the supinator muscle and at Henry's leash. The nerve was freed, and the tendon of the extensor index proprius was transferred to the extensor pollicis longus. Six months after the procedure, the patient had resumed her daily activities, showing a good functional result.

Cerebral Hypoperfusion in Posterior Reversible Encephalopathy Syndrome is Different from Transient Ischemic Attack on CT Perfusion.

BACKGROUND: PRES is a reversible neurotoxic state presenting with headache, altered mental status, visual loss, and seizures. Delayed diagnosis can be avoided if radiological patterns could distinguish PRES from cerebral ischemia. METHODS: Clinical and radiological data were collected on all hospitalized patients who had (1) discharge diagnosis of PRES and (2) acute CTP/CTA. Data were compared with 10 TIA patients with proven cytotoxic edema on MRI. RESULTS: Of the four PRES patients found, three were correlated with acute blood pressure and one with chemotherapy. At the radiological level, quantitative analyses of the CTP parameters showed that 2 out of 4 patients had bilaterally reduced CBF-values (23.2-47.1 ml/100g/min) in occipital regions, as seen in the pathological regions of TIA patients (27.3 ± 13.5 ml/100g/min). When compared with TIA patients, the pathological ROI's demonstrated decreased CBV-values (3.4-5.6 ml/100g). Vasogenic edema on MRI FLAIR imaging was seen in only one PRES patient, and cytotoxic edema on DWI-imaging was never found. CT angiography showed in one PRES patient a vasospasm-like unilateral posterior cerebral artery. CONCLUSIONS: If confirmed by other groups, CTP and CTA imaging in patients with acute visual loss and confusion may help to distinguish PRES from bi-occipital ischemia. These radiological parameters may identify PRES patients at risk for additional tissue infarction.

A Less Known Stroke Mimic: Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuro-radiological diagnosis, which can complicate a wide range of conditions. Clinical features include generalised and/or focal neurological deficits. These features are also present in neurovascular disorders, such as stroke. Currently, emphasis in the management of hyperacute stroke is thrombolysis, and it is important to bear in mind stroke mimics as a possible cause of clinical features. The Authors present the case of a 66-year-old man, who presented with acute focal neurological deficit. His brain imaging and history were consistent with PRES.

Intra and inter-examiner reliability of the subacromial impingement index

The present study aimed to assess the reliability of intra and inter-examiner subacromial impingement index (SII) measures obtained from radiographs. Thirty-six individuals were enrolled and divided into two groups: control group, composed of 18 volunteers in good general health without shoulder problems, and a group of 18 patients with subacromial impingement syndrome (SIS). Radiographic images were taken with the dominant upper limb in neutral rotation, while the volunteers held their arm at 90A degrees of abduction in the frontal plane. The beam of radiation at 30A degrees craniocaudal inclination was used to provide an antero-posterior image view. Three blinded examiners each performed three measurements from the subacromial space (SS) and the anatomical neck of the humerus (NH). The SII was calculated as the ratio of the SS and the NH measures. The mean values of SII were compared using t-tests. The intra-class correlation coefficient (ICC) was used to assess intra- and inter-examiner reliability of the measures. The mean values of SII were greater for the control group (0.12) than for the SIS group (0.08; p = 0.0071). SII measurements showed excellent intra (0.96-0.99) and inter-examiner reliability (0.94) for both the control and SIS group. The results of this study show the potential use of the SII; a greater mean value for the control group compared to the SIS group and excellent reliability for intra- and inter-examiner measurement. Validation studies of the index should be conducted to correlate the index with clinical findings from subacromial impingement syndrome.

Fissures du labrum glénoïdal postérieur et lésions associées de l'épaule: une étude en arthroscanner [Fissures of the posterior labrum and associated lesions: CT arthrogram evaluation]

PURPOSE: To describe osseous, chondral and tendinous lesions associated with fissures of the posterior labrum. To better understand the pathological processes leading to fissure of the posterior labrum. Materials and methods. Retrospective study of 43 CT arthrograms performed in 43 patients that showed a fissure of the posterior labrum. The following associated lesions were noted: osseous and chondral remodeling of the humeral head and/or glenoid and articular surface fissures of the rotator cuff. Based on type of associated lesions, patients were separated into one of four pathological subgroups: posterior instability, posterosuperior or internal impingement, anterior instability and isolated fissure of the posterior labrum. RESULTS: Sixteen patients (37.2%) of patients showed posterior instability, 12 (27.9%) showed lesions of internal impingement, and 11 (25.6%) showed lesions of anterior instability. Only 4 patients (9.3%) had an isolated fissure of the posterior labrum. CONCLUSION: Posterior instability, internal impingement and anterior instability are the main pathologies leading to fissure of the posterior labrum, which seldom occurs in isolation. Evaluation of these associated lesions allows understanding of the underlying pathological processes leading to fissure of the posterior labrum.

Hip arthroscopy after previous surgical hip dislocation for femoroacetabular impingement

PURPOSE: The purpose of this study was to examine whether arthroscopic adhesiolysis can relieve symptoms of patients with persistent pain after open surgical hip dislocation for femoroacetabular impingement syndrome without osseous or cartilaginous alterations. METHODS: This study comprised 16 consecutive patients (6 men and 10 women; mean age, 33.5 years [range, 19 to 60 years]) with persistent pain without osseous or cartilaginous alterations after surgical hip dislocation for the treatment of femoroacetabular impingement. At index surgery, all patients had osteochondroplasty of the head-neck junction and resection of the acetabular rim with reattachment of the labrum in 9 cases. All patients had preoperative magnetic resonance imaging-arthrogram and were treated with arthroscopy of the hip. RESULTS: At arthroscopy, all reattached labra were stable. In the cases without preservation of the labrum at the index operation, the joint capsule was attached at the level of the acetabular rim and synovitis was noticed. All patients had adhesions between the neck of the femur and joint capsule or between the labrum and capsule. In 3 patients the arthroscopic procedure was technically limited by massive thickening of the capsule. Overall, 81% of patients (13/16) showed less pain or were pain-free. The Merle d'Aubigné score improved from 13 points preoperatively to 16 points at the last follow-up. CONCLUSIONS: Persistent pain after surgical dislocation of the hip without evidence of cartilaginous and osseous alterations could result from intra-articular adhesions. Hip arthroscopy after previous surgery can be demanding because of scarring. If the adhesions can be released, good results can be achieved. LEVEL OF EVIDENCE: Level IV, therapeutic case series.